- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $596.16 / $798.44 / $798.44
| Professional | | $596.16 | $798.44 | $798.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $542.66 / $542.66 / $542.66
| Facility | | $542.66 | $542.66 | $542.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $396.14 / $542.66 / $558.94
| Professional | | $396.14 | $542.66 | $558.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $542.66 / $542.66 / $542.66
| Facility | | $542.66 | $542.66 | $542.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $542.66 / $542.66 / $558.94
| Professional | | $542.66 | $542.66 | $558.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $430.67 / $1,064.58 / $1,104.20
| Professional | | $430.67 | $1,064.58 | $1,104.20 |